Healthcare Provider Details

I. General information

NPI: 1215863626
Provider Name (Legal Business Name): MARESA MCKRAKEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 OLD JACKSONVILLE RD
SPRINGFIELD IL
62704-7437
US

IV. Provider business mailing address

100 MESA RD APT 3
SPRINGFIELD IL
62702-1595
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-9722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number041376487
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: